MEDICARE: MR. ROBERT HENRY ANDERSON RCSW-I

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	7120	FL

General Provider Information

NPI Number	:	1912294158
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ROBERT HENRY ANDERSON RCSW-I

Provider Business Mailing Address
First Line	:	590 NW PEACOCK BLVD
Second Line	:
City	:	PORT ST LUCIE
State	:	FL
Zip	:	34986-2213
Country	:	US
Telephone Number	:	772-344-4020
Fax Number	:	772-344-4038

Provider Business Practice Location Address
First Line	:	590 NW PEACOCK BLVD
Second Line	:
City	:	PORT ST LUCIE
State	:	FL
Zip	:	34986-2213
Country	:	US
Telephone Number	:	772-344-4020
Fax Number	:	772-344-4038

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/08/2011
Last Update Date	:	07/08/2011

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